In order to submit an insurance claim electronically, you must activate "Java Script" in your web browser.

Policyholder*

Policy No.*

Validity term of the policy from (dd.mm.yyyy)*

Validity term of the policy to (dd.mm.yyyy)*

Insured person*

Personal identification code*

Address*

Post code*

Phone no.*

Fax no.

E-mail*

Insurance event date (dd.mm.yyyy)*

Country, city, where insurance event occurred*

Event description*

Diagnosis

Where and what assistance provided(Assistance type / Value / Service fee / Who paid for)

Выгодоприобретатель

First name, Last name

Personal identification code

Bank account no.

Attached documents

Max 5 MB

Max 5 MB

Max 5 MB

Max 5 MB

Max 5 MB

Please wait! Data processing takes place.

Only when a message appears on the screen and a copy of your claim is received in your e-mail box, your claim has been sent successfully.

Warning!

Claim sending failed! Please try again by pressing the button "Send it again!"

With this I undertake to provide all the information at my disposal regarding the mentioned event, as well as co-operate to obtain additional information necessary for reviewing this insurance claim.If the information regarding the conditions of the event provided by me is delusive or false, or if the orders of the insurer will not be followed, the insurance indemnity will be decreased or rejected.